Update Alert 11: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers
Authors: Roger Chou, Tracy Dana, David I. Buckley, Shelley Selph, Rongwei Fu, Annette M. Totten
Journal: Annals of Internal Medicine (2022)

LettersAugust 2022Update Alert 11: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care WorkersFREERoger Chou, MD, Tracy Dana, MLS, David I. Buckley, MD, MPH, Shelley Selph, MD, MPH, Rongwei Fu, PhD, Annette M. Totten, PhDRoger Chou, MDPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon, Tracy Dana, MLSPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon, David I. Buckley, MD, MPHPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, Oregon, Shelley Selph, MD, MPHPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon, Rongwei Fu, PhDPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, Oregon, Annette M. Totten, PhDPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L22-0235 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail This is the 11th and final update alert for a living rapid review on the epidemiology of and risk factors for coronavirus infection in health care workers (HCWs) (1). Updates were monthly through update alert 7 (2), bimonthly for updates 8 (3) and 9 (4), and then biannual. Searches for this update were done from 25 October 2021 to 24 May 2022 using the same search strategies as the original review. The update searches identified 8552 citations. We applied the same inclusion criteria used for prior updates, with previously (5) described protocol modifications to focus on risk factors for coronavirus infections and higher-quality evidence (studies reporting adjusted risk estimates).The original rapid review included 34 studies on risk factors for coronavirus infections (3 studies on SARS-CoV-2) (1); 124 studies (122 studies on SARS-CoV-2) were added in prior updates (2–10). Twenty new studies on risk factors for SARS-CoV-2 infection were added for this update (Supplement Tables 1 to 8) (11–30). The studies were based on data collected through the end of 2020 in 10 studies (11–13, 15–17, 23, 24, 27, 30) and through June 2021 in 9 studies (14, 18–22, 25, 26, 29). One new study collected data in South Africa in November and December 2021 during the initial Omicron variant surge (28). Of the 20 new studies, 7 were cohort studies (14, 16, 20, 23, 25, 26, 29), 12 were cross-sectional studies (11–13, 15, 17–19, 22, 24, 27, 28, 30), and 1 was a case–control study (21) (Supplement Table 1). Ten studies were done in Europe, 3 in Africa, 1 in the Middle East, and 5 in North America. As with previously included studies, the new studies had methodological limitations, including potential recall bias, limited adjustment for potential confounders (including SARS-CoV-2 exposures), and low or unclear participation rates.The new studies were generally consistent with prior updates on the association between demographic characteristics and risk for SARS-CoV-2 infection in HCWs (Supplement Table 2). There was no consistent association between age (16 studies [11, 13, 14, 16–27, 29]) or sex (16 studies [11, 13, 14, 16–27, 29]) and risk for SARS-CoV-2 infection. Seven new studies were consistent with prior evidence suggesting an increased risk for SARS-CoV-2 infection among Black or Hispanic HCWs compared with White or non-Hispanic HCWs (12, 13, 18, 20, 23, 26, 27). Sixteen new studies evaluated the association between various HCW roles and risk for infection, most commonly nurse versus physician (12–14, 17–27, 29, 30). Among 11 studies, 8 studies found that being a nurse was associated with a higher risk for SARS-CoV-2 infection than being a physician, and 3 studies found similar risk. The new studies did not change the overall finding of no clear association between nurse versus physician HCW role and risk for SARS-CoV-2 infection given inconsistency in findings, including prior studies showing physicians being at higher risk.New for this update, 3 studies found that prior SARS-CoV-2 infection or positive vaccination status was associated with decreased risk for SARS-CoV-2 reinfection or infection among HCWs (Supplement Table 3) (26, 28, 29). In 1 study done during the Omicron variant surge, prior SARS-CoV-2 infection confirmed by polymerase chain reaction test was associated with decreased risk for reinfection (adjusted odds ratio, 0.55 [95% CI, 0.36 to 0.84]) (28). In this study, HCWs with 2 doses of the BNT162b2 vaccine were at decreased risk for infection compared with those who were unvaccinated, although the difference was not statistically significant (adjusted odds ratio, 0.59 [CI, 0.23 to 1.57]). One pre-Omicron study found that prior infection was associated with a reduced risk for reinfection among unvaccinated persons (adjusted incidence rate ratio, 0.15 [CI, 0.08 to 0.26]) and that full vaccination (2 doses) was associated with decreased risk versus no vaccination (adjusted incidence rate ratio, 0.10 [CI, 0.02 to 0.38]) (26); another pre-Omicron study found that full vaccination was associated with decreased risk versus no vaccination (adjusted hazard ratio, 0.37 [CI, 0.29 to 0.69]) (29).Fourteen new studies reported on the association between exposures and likelihood of SARS-CoV-2 infection among HCWs (Supplement Table 4) (11–13, 15–22, 24, 26, 30). As in prior updates, greater exposure was generally associated with increased risk for SARS-CoV-2 infection. Thirteen studies found that direct contact with a patient with COVID-19 or working in a setting at high risk for exposure to a patient with COVID-19 was associated with increased risk for SARS-CoV-2 infection versus no direct contact or working in a lower-risk setting, but risk estimates were imprecise or not consistently statistically significant in most studies, and exposure definitions and comparisons varied (11–13, 15–22, 24, 26). No new study evaluated the association between education or training and risk for SARS-CoV-2 infection (Supplement Table 5).Three new studies reported on the association between mask use and SARS-CoV-2 infection (Supplement Table 6). One new publication for a previously included study found that use of an N95 mask was associated with an increased risk for SARS-CoV-2 infection versus nonuse in a univariate analysis (odds ratio, 7.8 [CI, 4.0 to 15.2]) (16). However, N95 use was not included in the multivariate model, and the observed association is likely related to confounding from increased exposures or other factors in HCWs using N95 masks. Two other new studies of mask use are consistent with prior updates that suggest mask use reduces risk for SARS-CoV-2 infection, but risk estimates were not statistically significant (20, 23). Neither study reported mask type, and both were susceptible to potential recall bias.Consistent with previously reviewed evidence, 1 new study found that appropriate use of personal protective equipment was associated with decreased risk for SARS-CoV-2 infection compared with suboptimal use when participating in several patient care activities (Supplement Table 7) (15). However, findings were limited by unclear definitions for "appropriate" and "suboptimal" personal protective equipment use.A summary of all evidence identified through this final update is shown Supplement Table 8. Despite large numbers of studies and participants, evidence remains low for most risk factors because of limited evidence, methodological limitations, imprecision, and inconsistency. Moderate evidence indicates no association between age, sex, or HCW role (nurse vs. physician) and risk for SARS-CoV-2 infection; an association between Black race or Hispanic ethnicity (vs. White race or non-Hispanic ethnicity) and increased risk for SARS-CoV-2 infection; and an association between personal protective equipment use and decreased risk for SARS-CoV-2 infection.References1. Chou R, Dana T, Buckley DI, et al. Epidemiology of and risk factors for coronavirus infection in health care workers. A living rapid review. Ann Intern Med. 2020;173:120-136. [PMID: 32369541] doi:10.7326/M20-1632 LinkGoogle Scholar2. Chou R, Dana T, Selph S, et al. Update alert 7: epidemiology of and risk factors for coronavirus infection in health care workers. Ann Intern Med. 2021;174:W45-W46. 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[PMID: 35296242] doi:10.1186/s12879-022-07222-8 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, OregonPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, OregonPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonDisclaimer: The original review was funded by the World Health Organization. The World Health Organization staff developed the key questions and scope for the original review but did not have any role in the selection, assessment, or synthesis of evidence for this update.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L22-0235.Corresponding Author: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, [email protected]edu.This article was published at Annals.orgon 12 July 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoUpdate Alert: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 2: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. 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Buckley , and Rongwei Fu Update Alert 8: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 9: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , Shelley Selph , Annette M. Totten , David I. Buckley , and Rongwei Fu Update Alert 10: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Metrics August 2022Volume 175, Issue 8Page: W83-W84 ePublished: 12 July 2022 Issue Published: August 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...